Kajal Manchanda

Allopurinol induced granuloma annulare in a patient of lepromatous leprosy

Granuloma annulare (GA) is a benign, inflammatory dermatosis involving dermis or subcutis with unknown etiology and poorly understood pathology. GA has characteristic histological features of necrobiosis, granuloma formation and abundant mucin deposition. Various predisposing factors, systemic diseases and drugs have been implicated in the etiology. We hereby describe a case of 70 year old male who was a known case of lepromatous leprosy, taking multidrug therapy for 6 months presented with multiple discrete, annular, firm, non tender, smooth surfaced skin colored papular lesions ranging in size from 0.5-1 cm over back for 1 month. There was past history of intake of allopurinol for hyperuricemia which was started 1 year back. There was history of similar lesions 6 months back which healed within 1 month of stopping allopurinol and he started taking the drug for the past 4 months on his own without any medical advice. Histopathological examination showed superficial and deep perivascular lymphocytic infiltrate with numerous histiocytes scattered in the intersititum of reticular dermis and abundant mucin in between the histiocytes. Allopurinol was implicated as an etiological agent and dramatic improvement was seen after stopping the drug for a period of 4 weeks. Naranjos algorithm showed a probable association with a score of 6. Thus the final diagnosis of allopurinol induced generalised interstitial granuolma annulare was made. Patient was advised to continue antileprotic drugs, low purine diet and avoid allopurinol intake.

Hypohidrotic ectodermal dysplasia

Ectodermal dysplasias (ED) are a group of inherited disorders characterized by dysplasia of structures of ectodermal origin, clinically classified into hypohidrotic and hidrotic forms. A 21-year-old female presented with history of hypohidrosis, thinning of scalp and eyebrow hair, xerotic skin, and periorbital and perioral wrinkling. There was hypodontia and peg-shaped teeth on intraoral examination. Routine investigations were normal, orthopantomogram revealed absence of multiple teeth with peg-shaped teeth. Histopathological examination showed thinned epidermis and reduction in the number of eccrine units. Thus, the diagnosis was confirmed as Hypohidrotic ED.

Acroangiodermatitis (Pseudo-Kaposi sarcoma).

Acroangiodermatitis or Pseudo-Kaposi sarcoma is a rare angioproliferative entity, related to chronic venous insufficiency or certain other vascular anomalies. It is often associated with chronic venous insufficiency, arteriovenous malformation of the legs, chronic renal failure treated with dialysis, paralyzed legs and amputation stumps. We hereby describe a case of 45 year old female presenting with pitting pedal edema, multiple ulcers over bilateral lower limbs with irregular margins with erythema and hyperpigmentation of the surrounding skin. Color Doppler study of bilateral lower limbs was normal. Histopathological examination from one of the lesions showed hyperplastic epidermis, proliferation of capillaries in dermis, hemosiderin deposits and lymphocytic infiltrate. These features thus confirmed the diagnosis of Acroangiodermatitis.

Brooke-spiegler syndrome: a rare entity.

Brooke-Spiegler syndrome (BSS) is a rare autosomal dominant disorder characterized by the presence of various adnexal tumors including multiple cylindromas, trichoepitheliomas and spiradenomas. A 35-year-old female presented with multiple asymptomatic nodular lesions over face and scalp since the age of 5 years. There were no complaints suggestive of systemic involvement. Her son, elder sister, younger sister, father, fathers sister, and grandmother had history of similar lesions. On examination, there were multiple asymptomatic skin-colored firm papulonodular lesions measuring from 2 to 8 mm in diameter, with smooth surface mainly affecting central part of face. Scalp showed pinkish, firm, smooth-surfaced, dome-shaped nodules measuring about 1 to 3 cm in size. Histopathological examination was consistent with trichoepitheliomas for the facial lesions and cylindromas for the scalp lesions. The diagnosis of BSS was thus confirmed.

Role of caffeine in the management of androgenetic alopecia

Androgenetic alopecia (AGA) is hereditary and androgen-dependent, progressive thinning of the scalp hair that follows a defined pattern. It is a common dermatological problem affecting both men and women, with significant negative impact on their social and psychological well being.[1] It commonly begins by 20 years of age and affects nearly 50% of men by the age of 50 years.[1] Its etiopathogenesis is mainly androgen dependent and modulated via the testosterone metabolite dihydrotestosterone (DHT) and the expression of hair follicle-related androgen receptor.[2] The genetic factors also have been implicated in the pathogenesis of AGA.[2] Patients afflicted with AGA suffer from severe impairment of quality of life and thus treatment of this condition is mandatory, requiring long-term treatment with chief concerns about the efficacy and safety of the product used. Currently only oral finasteride and topical minoxidil are approved for treatment of AGA. [3,4] Recently, certain newer advances have shown caffeine to have beneficial effects in patients suffering from AGA. The proposed mechanism which would counteract DHT-induced miniaturization of the hair follicle include inhibition of phosphodiesterase by caffeine, which increases cAMP levels in cells and therefore promotes proliferation by stimulating cell metabolism.[5] A study conducted by Fischer et al. used hair organ culture model to investigate the effects of testosterone and caffeine on hair follicle growth stimulation. This in vitro study used scalp biopsy samples from male AGA patients which were cultivated using different concentrations of testosterone and/or caffeine for a period of 120-192 hours. Addition of caffeine in concentrations of 0.001% and 0.005% were found to counteract the suppressive effects of testosterone on hair growth, with a higher hair shaft elongation seen at 120 h after caffeine administration, compared to control group. This in vitro study thus clearly demonstrates that caffeine is a stimulator of human hair growth which may have importance in the treatment of AGA.[5] Brandner et al. proved by their double-blind placebo-controlled trial that caffeine application causes a substantial reduction in the transepidermal water loss in men compared to women, thus improving barrier function in men.[6] Regarding the route of delivery of caffeine, hair follicles are considered an important route for drug delivery. A recent study which assessed the follicular penetration of topical caffeine in hair follicles proved hair follicles to be faster route of drug delivery for topically applied drugs.[7] An important requirement for the treatment of AGA is follicular drug delivery. A recent study assessed the follicular penetration of caffeine on topical application in a shampoo formulation for 2 min and showed that penetration via hair follicles was faster and higher compared with the interfollicular route and that hair follicles were the only pathway for faster caffeine absorption during the first 20 min after application.[8]

Misuse of topical corticosteroids over face: A clinical study

Introduction: Topical corticosteroids (TCS) have been widely used in various dermatological diseases. However, because of inadvertent use, TCS misuse has become a common problem faced by dermatologists in various parts of the world. Prolonged use over the face can cause various side effects such as steroid rosacea, acneiform eruptions, and hypertrichosis. Aim: To study the effects of TCS misuse and analyze various factors promoting its use on face. Materials and Methods: A total of 100 patients presenting with various facial dermatoses following the misuse of TCS on the face were studied. Detailed history was noted and the various side effects were recorded. Results: Majority of the patients (70%) were females with maximum number of patients belonging to the age group of 11–20 years. Eighty-five percent of the patients were applying TCS for medical conditions, with acne being the most common indication, and the rest were applying as a general face cream. Pruritus and acneiform eruptions were the most common side effects observed and the other reported were erythema, photosensitivity, steroid dependent face, and telangiectasia. Conclusion: TCS misuse especially over the face can lead to a multitude of side effects. It is high time to create awareness among the patients as well as doctors regarding the proper usage of this wonder drug.

Familial type IIa hyperlipoproteinemia presenting with different types of xanthomas

A 12-year-old non-obese male presented with multiple yellowish, non-tender soft papulonodular lesions over multiple sites along with firm, subcutaneous swellings along achilles tendons bilaterally since the age of 2 years. There was no history of similar complaints in family. Lipid profile revealed high levels of serum cholesterol and low density lipoproteins. Histopathological examination revealed diffuse dermal infiltrate of foamy histiocytes. He was diagnosed as a case of Type IIa hyperlipoproteinemia with different types of xanthomas. The patient was adviced dietary fat intake control and started on tablet atorvastatin 40 mg daily. Complete work up of all the other family members was adviced.

Annular alopecia areata: report of two cases.

Alopecia areata (AA) is an auto-immune disorder characterized by the appearance of non-scarring bald patches affecting the hair bearing areas of the body. Scalp is the most common site of involvement. AA can affect any age group. The usual pattern of the hair loss is oval or round. We hereby, report two cases of annular and circinate pattern of AA due to its unusual morphology.

Atrichia with papular lesions.

Atrichia with papular lesions (APL) is a rare autosomal recessive form of irreversible alopecia with onset at few months of age with papular keratin cysts over the body. It is associated with mutation in the Zinc finger domain of the human hairless gene on chromosome region 8p12. An eleven-year-old male presented with extensive alopecia starting at six months of age refractory to the treatment along with keratotic papules on the face and trunk. Biopsy from a papule showed mid-dermal keratin cysts and from the scalp showed few vellus follicles with no terminal hairs. The diagnosis of APL was made based upon the criteria proposed. Vitamin D-dependent rickets was ruled out as it has similar clinical presentation. Accurate diagnosis of APL is required to avoid unnecessary treatment to the patient as it is commonly misdiagnosed as alopecia universalis and treated with systemic steroids.

Localized hypertrichosis following vaccination in an infant

Hypertrichosis is characterized by increased hair growth independent of androgen excess. There are various causes of acquired localized hypertrichosis including chronic irritation and inflammation. Localised hypertrichosis following pentavalent vaccine has not been described previously in Indian literature. We hereby report a case of a 4-month-old healthy infant presenting with focal circumscribed areas of hypertrichosis over anterolateral aspect of bilateral thighs at the site of vaccination.